Form DS-1843, Medical History and Examination for Individuals Age 12 and Older Instructions

Check this box if the abdomen evaluation is normal.

Check this box if the abdomen evaluation reveals any abnormalities.

Check this box if the abdomen was not evaluated.

Provide detailed notes on any abnormalities observed during the clinical evaluation, including the pertinent item number before each comment.

Check this box if the employee/applicant/sponsor is with the U.S. Department of State.

Check this box if the employee/applicant/sponsor is with the U.S. Agency for International Development (USAID).

Check this box if the employee/applicant/sponsor is with the Foreign Commercial Service (FCS).

Check this box if the employee/applicant/sponsor is with the Foreign Agricultural Service (FAS).

Check this box if the employee/applicant/sponsor is with the U.S. Agency for Global Media.

Check this box if the employee/applicant/sponsor is a civilian employee of the Department of Defense.

Check this box if the employee/applicant/sponsor is employed as a contractor for the Department of Defense.

Check this box if the employee/applicant/sponsor works for another government agency and write the agency name on the adjacent line.

If the examinee/applicant/sponsor works for a government agency not listed among the checkboxes, enter the full name of that other government agency here.

Check this box if the employee/applicant/sponsor works for a contracting company and enter the company name on the adjacent line.

If the examinee/applicant/sponsor is employed by a contracting company, enter the full legal name of the contracting company here.

Check this box if the Anus/Rectum/Prostate evaluation findings were normal.

Check this box if the Anus/Rectum/Prostate evaluation findings were abnormal.

Check this box if the Anus/Rectum/Prostate was not evaluated.

Enter the assessment or problem list.

Check this box if the breasts evaluation is normal.

Check this box if an abnormality is found during the breasts evaluation.

Check this box if the breasts were not evaluated.

Check this box if the cardiovascular evaluation indicates no abnormalities.

Check this box if the cardiovascular evaluation indicates abnormalities.

Check this box if the cardiovascular evaluation was not performed or evaluated.

Enter the results of the Chest X-Ray.

Enter the date the Chest X-Ray was performed or the results were obtained.

Enter the examinee's chosen or preferred name (nickname or the name they use) exactly as they want it recorded on the form.

Provide the examinee's height in inches.

Provide the examinee's height in centimeters.

Provide the examinee's weight in pounds.

Provide the examinee's weight in kilograms.

Provide the examinee's Body Mass Index.

Provide the examinee's pulse rate.

Provide the examinee's sitting blood pressure reading.

Enter the examinee's date of birth.

Enter the date the medical examination was performed.

Provide the first drug or other allergy.

Provide the second drug or other allergy.

Provide the third drug or other allergy.

Provide the fourth drug or other allergy.

Provide the fifth drug or other allergy.

Provide the sixth drug or other allergy.

Provide the seventh drug or other allergy.

Provide the eighth drug or other allergy.

Provide the ninth drug or other allergy.

Provide the tenth drug or other allergy.

Enter the primary e-mail address where the examinee (or parent for a child under 18) can be reached for the next 90 days.

Enter a secondary e-mail address to be used if the primary address is not available during the next 90 days.

Check this box if the evaluation of the ears, nose, and throat is normal.

Check this box if the evaluation of the ears, nose, or throat reveals an abnormality.

Check this box if the ears, nose, and throat were not evaluated.

Enter the results of the ECG test.

Enter the date the ECG test was performed.

Enter the date of the eighth hospitalization, operation, or medical evacuation.

Provide details of the illness or operation for the eighth hospitalization or medical evacuation.

Enter the name of the hospital for the eighth hospitalization or medical evacuation.

Provide the city and state of the hospital for the eighth hospitalization or medical evacuation.

Enter the name of the eighth medication the examinee is currently taking, including prescription, over the counter, vitamins, or herbs.

Enter the dosage and frequency for the eighth medication.

Provide additional details for the eighth medication, such as the reason for taking it or other relevant information.

Enter the date of the eleventh hospitalization, operation, or medical evacuation.

Enter the illness or operation related to the eleventh hospitalization, operation, or medical evacuation.

Enter the name of the hospital where the eleventh hospitalization, operation, or medical evacuation occurred.

Enter the city and state of the hospital where the eleventh hospitalization, operation, or medical evacuation occurred.

Check this box if the examinee is a Civil Service employee.

Check this box if the examinee is a Foreign Service (FS) Officer.

Check this box if the examinee is employed as a Personal Services Contractor (PSC).

Check this box if the examinee is employed by a third‑party contractor working for the agency.

Check this box if the examinee's employment status is CA‑EFM.

Check this box if the examinee is LES (Locally Employed Staff).

Check this box if the examinee is a Local National (LNA) employee.

Check this box if the examinee is serving as a Fellow.

Check this box if the examinee's employment status is EPAP.

Check this box if the examinee's employment status is not listed above and specify the status in the provided space.

Please enter the typed full name of the examiner.

Please enter the full address of the examiner.

Enter the signature of the examiner.

Enter the date the examiner signed.

Enter the examiner's telephone number.

Check this box if the eye evaluation is normal.

Check this box if the eye evaluation is abnormal. Remember to describe the abnormality in the 'Notes' section.

Check this box if the eye evaluation was not performed.

Check this box if the Female Gynecologic evaluation is normal.

Check this box if the Female Gynecologic evaluation is abnormal.

Check this box if the Female Gynecologic evaluation was not evaluated (NE).

Enter the date of the fifth hospitalization, operation, or medical evacuation.

Provide the illness or operation related to the fifth hospitalization, operation, or medical evacuation.

Enter the name of the hospital where the fifth hospitalization, operation, or medical evacuation occurred.

Provide the city and state of the hospital where the fifth hospitalization, operation, or medical evacuation occurred.

Enter the name of the fifth medication, including prescriptions, over-the-counter drugs, vitamins, or herbs.

Enter the dosage and frequency for the fifth medication.

Enter any additional details or purpose for the fifth medication.

Enter the date of the first hospitalization, operation, or medical evacuation.

Enter the illness or operation associated with the first hospitalization or medical evacuation.

Enter the name of the hospital where the first hospitalization or medical evacuation occurred.

Enter the city and state where the hospital for the first hospitalization or medical evacuation is located.

Enter the name of the first medication, including prescription drugs, over-the-counter medications, vitamins, and herbs.

Enter the dosage of the first medication.

Enter the frequency or instructions for taking the first medication.

Enter the date of the fourth hospitalization, operation, or medical evacuation.

Provide the illness or operation associated with the fourth hospitalization, operation, or medical evacuation.

Enter the name of the hospital for the fourth hospitalization, operation, or medical evacuation.

Provide the city and state where the hospital for the fourth hospitalization, operation, or medical evacuation is located.

Enter the name of the fourth current medication, including prescription, over-the-counter, vitamin, or herb.

Enter the dosage and frequency for the fourth current medication.

Provide any additional details or notes for the fourth current medication.

Check this box if the General/Constitution evaluation is normal.

Check this box if the General/Constitution evaluation is abnormal.

Check this box if the General/Constitution evaluation was not performed or evaluated.

Enter the full name of the examinee's health insurance plan (include provider name and any identifying policy or member number and plan type if applicable).

Check this box if the examinee has a history of receiving the BCG vaccine.

Check this box if the examinee does not have a history of receiving the BCG vaccine.

Provide the date of the BCG vaccine.

Enter the full name of the employee or applicant associated with this examinee if the examinee is an eligible family member.

Enter the Interferon Gamma Release Assay (IGRA) result.

Enter the date the Interferon Gamma Release Assay (IGRA) was performed.

Provide a detailed explanation for any question(s) 1–36 answered "Yes," including the question number(s), date(s) of occurrence, diagnosis or condition, treatment received (including medications and procedures), treating provider or facility, and current status or outcome. Fill only if 'Question 1 - Frequent/severe headaches or migraines: Yes', 'Question 2 (Fainting, dizzy episodes, or syncope?) - Yes', 'Question 3 (Stroke, TIA or head injury) — Yes', '4. Epilepsy, seizures or other neurologic disorders? — Yes', 'Question 5 (Eye or vision problems) - Yes', 'Question 6 (Ear, nose, throat problems; hearing loss, hoarseness?) — Yes', 'Question 7: Allergies or history of anaphylactic reaction? — Yes', 'Question 8 (Yes) - Shortness of breath, asthma, or COPD?', '9. History of abnormal chest x-ray? — Yes', 'Question 10 (Yes): History of positive TB skin test, IGRA, or tuberculosis', '11. Aneurysm, blood clot or pulmonary embolism? — Yes', 'Question 12: High blood pressure? — Yes', 'Question 13: Murmurs, palpitations, or other heart problems — Yes', 'Question 14 (Yes) - Are you a former or current smoker?', '15. Stomach, esophageal, or other intestinal problems? — Yes', 'Question 16 - Jaundice, hepatitis, or other liver disease: Yes', 'Question 17 (Yes) - Intestinal, rectal problems or hernia', 'Question 18 (Yes) - Urinary or kidney problems, blood in urine', '19. Diabetes, thyroid, or other endocrine disorders? — Yes', '20. Joint or back pain/injury? — Yes', 'Question 21 - Yes (Are you pregnant?)', '22. Rheumatologic disorder (Yes)', 'Question 23: Anemia — Yes', 'Question 24: Blood transfusion? — Yes', '25. Malaria, tropical or other infectious disease? — Yes', 'Question 26 — Any skin or nail disorder? (Yes)', '27. Cancer of any type? — Yes', 'Question 28 (Any thickening or lump in breast, testicle) — Yes', '29. Yes - Referred/evaluated for special educational services (IFSP/IEP/504)', '30. Psychotherapy or counseling — Yes', 'Question 31 - Yes: Prescribed medication for depression/anxiety/mood/memory/attention/other', 'Question 32 (Yes)', '33. Yes', 'Question 34 (1) - Yes: Hospitalized or engaged in self-injury/suicidal behavior in last 2 years', '35. Yes — Interested in consultation with Mental Health Specialist', 'Question 36 - Yes' is 'Yes' (any fields selection).

Check this box if the Lungs/Thorax evaluation is normal.

Check this box if an abnormality is found during the Lungs/Thorax evaluation.

Check this box if the Lungs/Thorax evaluation was not performed.

Check this box if the lymph nodes evaluation found them to be normal.

Check this box if the lymph nodes evaluation found them to be abnormal.

Check this box if the lymph nodes were not evaluated.

Check this box if the male genitalia evaluation is normal.

Check this box if the male genitalia evaluation is abnormal.

Check this box if the male genitalia evaluation was not performed or not applicable.

Provide comments on significant patient medical history and items checked 'yes' on page 2/section II, using additional pages if necessary.

Check this box if the Mental/Affect/Mood evaluation is normal.

Check this box if the Mental/Affect/Mood evaluation is abnormal.

Check this box if the Mental/Affect/Mood evaluation was not evaluated.

Check this box if the Musculoskeletal / Spine / Extremities evaluation findings are normal.

Check this box if any abnormality is found during the Musculoskeletal / Spine / Extremities evaluation.

Check this box if the Musculoskeletal / Spine / Extremities evaluation was not performed.

Enter the examinee's full name (first, middle, and last as applicable) exactly as it should appear on the form.

Enter the examinee's family/surname exactly as it appears on official documents.

Enter the examinee's given/first name as it appears on official documents.

Enter the examinee's middle initial (or full middle name if required) or leave blank if none.

Check this box if the Neck/Thyroid evaluation is normal.

Check this box if the Neck/Thyroid evaluation is abnormal.

Check this box if the Neck/Thyroid was not evaluated.

Check this box if the neurologic evaluation indicates normal findings.

Check this box if the neurologic evaluation indicates abnormal findings.

Check this box if the neurologic evaluation was not performed or evaluated.

Provide the date of the ninth hospitalization, operation, or medical evacuation.

Describe the illness or operation related to the ninth hospitalization or medical evacuation.

Provide the name of the hospital for the ninth hospitalization or medical evacuation.

Provide the city and state of the hospital for the ninth hospitalization or medical evacuation.

Enter the name of the ninth current medication, including prescription, over the counter, vitamins, or herbs.

Provide additional details for the ninth current medication, such as dosage or frequency.

Specify any drug or other allergies associated with the ninth current medication.

Enter the city where the examinee was born (e.g., city name as commonly written).

Enter the state, province, region, or equivalent administrative area where the examinee was born.

Enter the country where the examinee was born using the country's common name.

Enter the name or location of the proposed assignment post (for example, the embassy/consulate or city and country).

Enter the estimated date of arrival at the proposed post.

Enter the name or location of your current (present) assignment post (for example, the embassy/consulate or city and country).

Enter the estimated date of departure from your present post.

Check this box if the individual has a previous history of active tuberculosis.

Check this box if the individual does not have a previous history of active tuberculosis.

Enter the date of previous active tuberculosis.

Check this box if the examinee has a history of previous LTBI treatment.

Check this box if the examinee does not have a history of previous LTBI treatment.

Provide the date of the previous LTBI treatment.

Check this box if the examinee has a previous positive TST or IGRA test result.

Check this box if the examinee does not have a previous positive TST or IGRA test result.

Provide the date of the previous positive TST or IGRA.

Check this box when the medical exam is being completed as part of pre-employment screening before beginning a new job or appointment.

Check this box when the medical exam is being completed while you are currently employed for routine, periodic, or job-related health evaluation.

Check this box when the medical exam is being completed because you are separating from or terminating employment/service.

Check this box when the exam is being completed for REA-WAE purposes as indicated by your assignment or employing office.

Check this box if the examinee has a history of frequent or severe headaches or migraines.

Check this box if the examinee does not have a history of frequent or severe headaches or migraines.

Check this box if the examinee (or parent for children under 18) has a history of a positive TB skin test, a positive IGRA, or a diagnosis of tuberculosis.

Check this box if the examinee (or parent for children under 18) does NOT have a history of a positive TB skin test, a positive IGRA, or a diagnosis of tuberculosis.

Check this box if the examinee has a history of an aneurysm, blood clot, or pulmonary embolism.

Check this box if the examinee does not have a history of an aneurysm, blood clot, or pulmonary embolism.

Check this box if the examinee (or parent for children under 18) has a history of high blood pressure.

Check this box if the examinee (or parent for children under 18) does not have a history of high blood pressure.

Check this box if the examinee has a history of murmurs, palpitations, or any other heart problems (answer = Yes).

Check this box if the examinee does not have a history of murmurs, palpitations, or any other heart problems (answer = No).

Check this box if the examinee is or has been a smoker (i.e., is a current smoker or a former smoker).

Check this box if the examinee has never been a smoker (i.e., is not a former or current smoker).

Check this box if the examinee has a history of stomach, esophageal, or other intestinal problems.

Check this box if the examinee does not have a history of stomach, esophageal, or other intestinal problems.

Check this box if the examinee has a history of jaundice, hepatitis, or any other liver disease.

Check this box if the examinee does NOT have a history of jaundice, hepatitis, or any other liver disease.

Check this box if the examinee (or the parent/guardian for a child under 18) has a history of intestinal or rectal problems or a hernia.

Check this box if the examinee (or the parent/guardian for a child under 18) does not have a history of intestinal or rectal problems or a hernia.

Check this box if the examinee has a history of urinary or kidney problems or has had blood in the urine.

Check this box if the examinee does not have a history of urinary or kidney problems and has not had blood in the urine.

Check this box if the examinee has a history of diabetes, thyroid disease, or any other endocrine disorder.

Check this box if the examinee does not have a history of diabetes, thyroid disease, or any other endocrine disorder.

Check this box if the examinee has a history of fainting, dizzy episodes, or syncope.

Check this box if the examinee does not have a history of fainting, dizzy episodes, or syncope.

Check this box if the examinee has a history of joint or back pain or injury (answer is Yes).

Check this box if the examinee does not have a history of joint or back pain or injury (answer is No).

Check this box if the examinee is currently pregnant (parents should answer on behalf of examinees under 18).

Check this box if the examinee is not currently pregnant (parents should answer on behalf of examinees under 18).

Check this box if the examinee has a history of a rheumatologic disorder (i.e., answer 'Yes' to question 22).

Check this box if the examinee has a history of anemia.

Check this box if the examinee does not have a history of anemia.

Check this box if the examinee has had a blood transfusion at any time (mark 'Yes' when a transfusion history is present).

Check this box if the examinee has never had a blood transfusion (mark 'No' when there is no history of transfusion).

Check this box if the examinee has a history of malaria, tropical disease, or any other infectious disease.

Check this box if the examinee does not have a history of malaria, tropical disease, or any other infectious disease.

Check this box if the examinee has a history of any skin or nail disorder.

Check this box if the examinee does not have a history of any skin or nail disorder.

Check this box if the examinee has a history of cancer of any type; if checked, provide a written explanation with date of occurrence in Box IIA.

Check this box if the examinee does not have a history of cancer of any type.

Check this box if the examinee has ever had a thickening or lump in the breast or testicle; if checked, provide a written explanation with date of occurrence in Box IIA.

Check this box if the examinee has never had a thickening or lump in the breast or testicle.

Check this box if, in the past two years, the examinee has been referred or evaluated for any special educational services, accommodations, or modifications (for example IFSP, Early Intervention, IEP, or 504 Plan).

Check this box if, in the past two years, the examinee has not been referred or evaluated for any special educational services, accommodations, or modifications.

Check this box if the examinee has a history of stroke, transient ischemic attack (TIA), or any head injury.

Check this box if the examinee does not have a history of stroke, transient ischemic attack (TIA), or head injury.

Check this box if, in the past two (2) years, the examinee has been in psychotherapy or counseling for treatment of anxiety, depression/mood problems, psychological trauma, or any other mental or behavioral health concerns.

Check this box if, in the past two (2) years, the examinee has not been in psychotherapy or counseling for anxiety, depression/mood problems, psychological trauma, or any other mental or behavioral health concerns.

Check this box if the examinee HAS been prescribed medication for depression, anxiety, mood or stress, memory/attention, or any other mental health or behavioral symptoms.

Check this box if the examinee has NOT been prescribed medication for depression, anxiety, mood or stress, memory/attention, or any other mental health or behavioral symptoms.

Check this box if the examinee has been diagnosed with an alcohol- or drug-related problem, medically advised to reduce use of a substance, or experienced a negative consequence due to substance use (e.g., legal infraction, medical or work problems).

Check this box if the examinee has not been diagnosed with an alcohol- or drug-related problem, has not been medically advised to reduce substance use, and has not experienced a negative consequence due to substance use.

Check this box if the examinee has experienced symptoms of an eating disorder (for example, a history of binging, self‑induced vomiting, use of laxatives/diuretics/enemas, or restrictive eating leading to extreme weight loss).

Check this box if the examinee has not experienced symptoms of an eating disorder as described in question 33.

Check this box if, in the past two years, the examinee has been hospitalized for a mental or behavioral health condition or has engaged in self-injury or suicidal behavior.

Check this box if, in the past two years, the examinee has NOT been hospitalized for a mental or behavioral health condition and has NOT engaged in self-injury or suicidal behavior.

Check this box if the examinee is interested in a consultation with a Mental Health specialist to help manage mental health treatment overseas.

Check this box if the examinee is not interested in a consultation with a Mental Health specialist for managing mental health treatment overseas.

Check this box if the examinee has any other medical or mental health condition not covered in questions 1–35.

Check this box if the examinee does NOT have any other medical or mental health condition beyond those listed in questions 1–35.

Check this box if the examinee has a history of epilepsy, seizures, or any other neurologic disorder (parents should answer for children under 18).

Check this box if the examinee does not have a history of epilepsy, seizures, or any other neurologic disorder (parents should answer for children under 18).

Check this box if the examinee (or the parent for children under 18) has a history of eye or vision problems.

Check this box if the examinee (or the parent for children under 18) does not have a history of eye or vision problems.

Check this box if the examinee has a history of ear, nose, or throat problems, hearing loss, or hoarseness.

Check this box if the examinee does not have a history of ear, nose, or throat problems, hearing loss, or hoarseness.

Check this box if the examinee has a history of allergies or an anaphylactic reaction.

Check this box if the examinee does not have a history of allergies or an anaphylactic reaction.

Check this box if the examinee has a history of shortness of breath, asthma, or chronic obstructive pulmonary disease (COPD).

Check this box if the examinee does not have a history of shortness of breath, asthma, or COPD.

Check this box if the examinee has ever had an abnormal chest x‑ray.

Check this box if the examinee has never had an abnormal chest x‑ray.

Provide detailed recommendations for treatment, further study, consultation, or follow-up.

Please enter the date of the second hospitalization, operation, or medical evacuation.

Please enter the illness or operation related to the second hospitalization, operation, or medical evacuation.

Please enter the name of the hospital for the second hospitalization, operation, or medical evacuation.

Please enter the city and state of the hospital for the second hospitalization, operation, or medical evacuation.

Enter the name of the first medication, including prescription, over-the-counter drugs, vitamins, or herbs.

Enter the dosage or strength of the first medication.

Enter the frequency or instructions for taking the first medication.

Provide the date of the seventh hospitalization, operation, or medical evacuation.

Describe the illness or operation for the seventh hospitalization, operation, or medical evacuation.

Enter the name of the hospital where the seventh hospitalization, operation, or medical evacuation occurred.

Provide the city and state where the hospital for the seventh hospitalization, operation, or medical evacuation is located.

Please provide the name of the seventh current medication.

Please describe the dosage, frequency, or any other relevant details for the seventh medication.

Please provide any additional information or reason for the seventh medication.

Check this box if the examinee's sex is male.

Check this box if the examinee's sex is female.

Enter the signature of the examinee or parent.

Enter the date the signature was provided.

Enter the date of the sixth hospitalization, operation, or medical evacuation.

Provide the illness or operation related to the sixth hospitalization or medical evacuation.

Enter the name of the hospital where the sixth hospitalization, operation, or medical evacuation occurred.

Provide the city and state of the hospital where the sixth hospitalization, operation, or medical evacuation occurred.

Enter the name of the sixth current medication being taken.

Enter the dosage or strength of the sixth current medication.

Enter the frequency or route of administration for the sixth current medication.

Check this box if the skin evaluation is normal.

Check this box if the skin evaluation is abnormal.

Check this box if the skin was not evaluated.

Check this box if the special assignment is a Temporary Duty (TDY) at a regional hub or within CONUS.

Check this box if the special assignment is to Iraq; use the adjacent space to list the specific post.

Enter the name of the Iraq post (city or specific post location) for the listed special assignment; if more than one, separate entries with commas. Fill only if 'Iraq - List Post' is 'Yes'.

Check this box if the special assignment is to any other ESCAPE post(s), and list the post(s) in the space provided.

List any other ESCAPE post(s) applicable to this assignment by name, separating multiple posts with commas. Fill only if 'Other ESCAPE Post(s)' is 'Yes'.

Check this box if the examinee's status is Spouse.

Check this box if the examinee's status is Dependent Child.

Check this box if the examinee's status is New Family Member.

Check this box if the examinee's status is Employee.

Check this box if the examinee's status is Applicant.

Enter the primary telephone number where the examinee (or parent if child) can be reached for the next 90 days.

Enter an alternate telephone number for the examinee (or parent if child) that can be used if the primary number is unavailable.

Enter the date of the tenth hospitalization, operation, or medical evacuation.

Provide the illness or operation associated with the tenth hospitalization or medical evacuation.

Enter the name of the hospital where the tenth hospitalization or operation occurred.

Provide the city and state of the hospital where the tenth hospitalization or operation occurred.

Enter the name of the tenth medication the examinee is currently taking.

Enter the dosage, frequency, or other relevant details for the tenth medication.

Enter the purpose for taking the tenth medication or the prescribing provider.

Enter the date of the third hospitalization, operation, or medical evacuation.

Enter the illness or operation related to the third hospitalization or medical evacuation.

Enter the name of the hospital for the third hospitalization or operation.

Enter the city and state where the third hospitalization or operation occurred.

Enter the name of the third medication, including prescription, over the counter, vitamins, or herbs.

Enter the dosage or frequency for the third medication.

Enter the start date or reason for taking the third medication.

Enter the TST result in millimeters of induration.

Enter the date the TST result was obtained.

Enter the date of the twelfth hospitalization, operation, or medical evacuation.

Provide the illness or operation associated with the twelfth hospitalization, operation, or medical evacuation.

Enter the name of the hospital for the twelfth hospitalization, operation, or medical evacuation.

Enter the city and state where the twelfth hospitalization, operation, or medical evacuation took place.